30 BERTUCCIO AVE - BPA-16-551 INSULATION l
/ Board of Building Regulations and Standard'�SP'rhe commonwealth of tviassachusetts
C1l � �C�I�Y OF
Massachusetts State Building Code, 780 CMR SALEtiI
��weal l5 a t�rrr�. v 2011
Building Permit Application To Construct,Repair, Renovate is a
One:or Two-Family DwelUng tt+t)i k i
This Section For Official Use only
(� Building Permit Number, Date. eds
19
-Building Official(Print Name). - -;�Stgnatttre : '. _ - Date
1 SECTION I:SITE INEORMATION`
Lt Pro erty ddres IZ Assessors Map dk Parcel Numbers
oe �
I.la is this on—accented street?yes •no Map Nutnber Parcel Nuryberglt it j,
1.3 Zoning Information: 1.4 Property Dimensions-' f7 ?:a= Y-! If
Zoning DiShiet :. .'Proposal Use Lot Arca(sq ft)
1.5 Building Setbacks(It)
Front Yard - - Side lYop6 - Itear Yard
Required .Provided Requited Provided-- . . .Requited . . .. Provided
1-7
1.6 Water Supply:(M.O.L c.40,§54) 11.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public 0 Private O. Municipal El On site disposal system 10- .
SECTION Z:;PROPERTY O}VNERSIIIe
_ ,. ram./ // �
z.1 Qn � / h.2roou C// lei' - {'�}
N'Itrte(Print) - . . city,State.ZIP .., - - - -
30 gerf tccc i d 14LR— Rio a33- y/7.3
No.and Street - Telephone Email Address
SECTION 3:DESCRIPTION OF 1?ROPOSED'WORKS(ebeek all tbntopply)
New Construction O •Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) 13 Addition 0
Demolition O AccessoryBldg.O . Numberof.Units_ Other O Specify:
Brief Description of Pro used Work=:
7777Z;; cry—2_ 7VC x,
-'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building IS I 1. Building Permit Fee:S indicate how fee is determined:
2. Electrical S O Standard Cityfrown Application Fee
O Total Ptoject Cost'(item 6)x multiplier
3. Plumbing I $ 2?Qther Fees: S _
4.Mcchanical (FIVAC) S List:
5.Mechanical (Fire 5
Su ressiun) Total All Fees:S
Check NoI.T36F Check Amount Cash Amount:
6.Total Project Cost: $ c2-7071 lo Paid in Full ❑Outstanding Balance Due:
rnP�ft_15r, SIZ-1 Tt� G . C.
V
�'it`.' ,• - SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Stipeivisor License(CSL)
FIE 'r.; �. . �C rre., .^ License Number Expiration Date .
W. �, ' A
Name of CSL Holder EnUMralm Lisf CSL"type(see below) tick
3 Milton Street T :-. Description .
Salem MA 01970 y
No.and Sweet_ U Uruestncted BwlJat up to 35,000 cu. R.
R Restricted M2 ly Dwellin
Cityfrown,State,ZIP M Masonry '
- RC Roorm Coverin
WS WindosvandSiJin
- -/, 2 SF Solid Fucl Burning Appliances
7g'��r/ " y J 1 1 Insulation
Tcic hone - . Email address D I Demolition' •a.
5.2 Regis d tto ! rovemeat Contractor(HIC)• �ZD frCl ='t3 )Z
apttCreaieruxuou, LLB
r - - - - - - - HIC Registration Number Expiration Dale
tI1CCompany - " '
r •A'n1079 — `-
No.mid Street '' I u Email address
rthis
frown State ZIP Telephone
SECT[ONti:.WORKERS'COh1PENSATION,INSURANCEAFFIDAVIT(fy1G.[: c-is2 25C(6
kers Compensation Insurance affidavit must be completed and submitted with this application..Failure to provideaffidavit will mutt in the denial of the Issuance buildied Affidavit Attached? Yes ...... No ••.17
SECTION 7a;OWNER AUTHORIZATIOM TO BE.COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAill' 9F0R1311'ItD11VG.PERMIT' `
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Or 's Name(Electronic Signature) q < Dote - -
SECTION 7b:OWNER'OR'AUTHORIZED AGENT DECLARATION
By entering my name below;I hereby attest under the pains and penalties of perjury that all of the information ,
contained in this application is a and accurate to the bat of my knowledge and understanding.,
s _ 1� M1
Print Owner's or Atahorii ed A c.V.Nome l learonic Signature) -
Date
NOTES:.
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_knot registered in the Home.lmprovement Contractor(HIC)Program);will no have access to the arbitration
program or guaranty fitnd under M.G.L.c. IJ2A.Other important inTorm- itio`n on the HICYrogra -can Gelou�r d3T -- -
www.mass.eoy'oce Inrormation on the Construction Supervisor License can be:round at www.nrass.uov7Jas
t 2. when substantial work is planned,provide the information below: -
total floor area(sq.R.) '} (including garage, finished basement/attics.decks or porch)
Gross living.area(sq.ttJ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of heating system. t Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may be,ubstituted 1•or"rutal Project Cost'